Fine Tuning The Antenna–Small Adjustments In ADHD Medicine Can Bring A Clear Picture

As we head into the last stretches of the school year, some kids are clearly having more difficulty with focus/concentration and impulse control.  Work habits are degrading and homework completion is increasingly difficult.  Teachers are having to reconnect some kids to the task at hand more frequently.  Others are having more impulsive behaviors toward peers in school.  In any case, there is still several months of school left and these issues need to be addressed.  As a clinician, I am often faced with the choice of making changes in the medication regimen.  So, do I fine tune the channel (make some small medication adjustments), or do I change the channel altogether (change the medicine completely).  Here is how I approach this issue when it presents.

It is important, of course, to consider the non-medication components of the child’s behavior and address any areas of concern.  Home and family issues can have a direct impact on a child’s ability to remain attentive and engaged in school.  Those issues should be screened for and addressed during individual/family therapy.  The intrusion of plain ‘ol bad habits regarding sleep can result in a child who stays up too late and is just tired during the day.  Who cares about algebra or world cultures when all you want to do is take a nap!?!  Nutritional issues need to be addressed as well, with care taken to ensure a reasonably broad diet, adequate intake of omega-3-fatty acids (fish oil), and adequate intake of Vitamin D (especially at this time of year).

Assuming that the above is addressed without improvement, small changes in medication can provide big benefits for the child.  When contemplating a change in stimulant medication to treat ADHD, there are two main factors to consider:  1) is the medicine working when it should be at its best; and 2) is the medicine lasting long enough.

First, is the medicine working?  While there can be an element of tolerance to a particular dose of stimulant medicine, most kids do not experience that as a clinically significant factor.  What does happen is that kids get bigger.  The effective dose of stimulant medication is greatly effected by a child’s weight.  Bigger kids need higher doses.  The dose of medicine that helped the 80-pound kid in September, might not do the trick for the 95-pound kid in March. While subjective rating scales are often used (for example, the teacher version of the Connors Scale), use of the Quotient-ADHD test in this instance is very helpful.  As you may know, this computer-based test allows clinicians to objectively measure the core attentive and hyperactive/impulsive symptoms seen in the ADHD syndrome.  It bypasses the subjective nature of the rating scales filled out by teachers and parents.  If the Quotient test shows signs of untreated ADHD symptoms, that would clearly indicate the potential benefit of increasing the dose of medicine.  If, on the other hand, Quotient testing indicate normal range attention and impulse control, it would indicate the need to step back and conduct a more extensive search for non-medication factors that might be contributing to these difficulties.

Second, is the medicine working long enough?  For some kids, the medicine works great . . . but just not long enough.  A child might do really well until the last class or two of the day.  Or might do well in school, but not be able to focus effectively on after school tasks.  Use of the Quotient system can be beneficial in this instance as well.  Having the child take the test in the mid-afternoon will objectively document the pattern of ADHD symptoms present at that time of day.  After making sure that an appropriate screening for environmental issues and sleep and nutritional issues takes place, it is reasonable to make some adjustments in medication.  There are two ways to address this.  First, the dose of the morning medication can be increased.  This can sometimes help the overall benefits last longer, but this is less likely to be helpful, unless there is evidence of a lack of benefit during the school day.  If a child is tolerating a medicine well, there is nothing to lose by doing a trial of a higher dose in the morning.  That keeps the dosing to once a day (always preferable), but it is important to make sure that afternoon symptoms are adequately covered.

The second way of addressing the ‘not-long-enough’ scenario is to add a booster.  Sometimes this is done at school, but my preference is to have the child take it right when they get home.  A booster is a shortest-acting version of whatever the extended release medication is.  For example, if a child takes Concerta, they would take a booster dose of Ritalin when they get home.  Ritalin is the active ingredient in Concerta.  If a child takes Adderall XR or Vyvanse, they would take a booster dose of dexedrine when they get home.  Dexedrine is the active ingredient in Adderall and Vyvanse.  As always, it is important to follow up to make sure that the anticipated benefits occur.

This time of year I prefer to do a fine-tuning of the antenna and save the changes of channel to summertime.  Making abrupt changes in medicine at this time of year risks dramatic worsening of behavior and attention abilities.  Whenever possible, I prefer to hold on to the gains that have been made and provide a little more medication support, a little more family support, and a little more school support to get a kid through the last three months of school.

–Dan Hartman, MD


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